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The first edition of the Peer-supported Open Dialogue Bulletin
Edited by Lucy Kilmartin and Tom Stockmann

Spring 2015
 
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The UK
Peer-supported Open Dialogue
Bulletin

Swallows, used in literature to symbolise the coming of Spring, and Hope.
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Introduction


Welcome to the first edition of the Peer-Supported Open Dialogue Bulletin. 

Following a hugely successful POD conference recently in London (more reflections on that from trainees and contributors, below), we wanted to build on the momentum generated through this, along with the work being undertaken across several UK NHS trusts, to keep dialogue flowing and people connected.

The essence of Open Dialogue is in the generation of shared meaning and shared experience, and that is something we want to try to foster, in some small way, through this quarterly publication. On a more practical front, we also aim to keep you updated on relevant news, events, publications and educational material. By receiving this bulletin, you become part of the wider network and so too does your voice - please add it to the polyphony of voices out there, through our readers' response section! We hope that this marks the start of something that can grow and evolve over time, as we learn from each other. 

Each edition of the POD bulletin features a number of sections, including a POD project update from Dr Razzaque, filling you in on the most recent developments across the pilot schemes so far, reflections from those training in Open Dialogue, and feedback from those working with families or networks. We also aim to include the perspectives of other network members, and in this way build up a more complete picture of how this approach is delivered and how, most importantly, it is experienced by health care professionals, service users and families alike.


Finally, at the end of this edition of the bulletin, you'll find a YouTube clip of the London conference. This is a brief excerpt designed to share on social media and help us spread the word far and wide. Please take a look and, by all means, send it out to your networks wherever and whenever you can.

We hope you enjoy what follows and look forward to hearing (and responding to!) your feedback.
 

 

What is Open Dialogue? A recap:


Studies In Finland - where Open Dialogue was first practised – have estimated that the model has enabled almost 85 per cent  of those presenting with acute psychosis to become almost symptom free, and return to employment, education or training, with less frequent use of hospitalisation or high dose medication. In the UK, far fewer currently achieve these outcomes.

Open Dialogue fully involves the person in distress and their social network, from the very beginning. Key principles include a flattened hierarchy, and a more democratic dynamic - where the aim is to 'be with', not 'do to' the patient. There is complete transparency, where all treatment decisions are discussed openly with the person concerned (an open dialogue).  

Open Dialogue has been adopted within Europe and in parts of the USA. A small group of dedicated mental health professionals are now introducing it to the UK, with the addition of fully involved peer workers.

Several NHS Trusts in the UK - including North East London NHS Foundation Trust (NELFT), North Essex, Nottinghamshire and Kent & Medway - are setting up pilot Peer-Supported Open Dialogue services over the next couple of years, where service users join the teams to help build social networks around patients who may lack support. 
 
The initiative, led by NELFT, is part of a proposed multi-centre trial to build the evidence base for such services in a UK context, with the ultimate intention of enabling more wider scale roll-out across NHS services, should the outcome improvement and cost reductions seen in other countries remain consistent.
 
Teams from the four NHS mental health trusts mentioned above have commenced training in the approach and the trial to compare it to current practice will start in 2016.
 

 

What has been achieved in 12 months?

 
  • Trusts have now signed up to train pilot teams, and they have all now started their first Open Dialogue cases
  • Interest in this project has sky rocketed in the meantime with several hundred people wanting to come to the first national conference (March 11, 2015)
  • Carers and service users who are coming into contact with Open Dialogue are becoming increasingly vocal advocates and now local and national groups are starting to lobby at all levels for its implementation
  • A large team of senior mental health academics have joined the research panel and are applying now for a large research grant to the NIHR (National Institute of Health Research)
  • Four more Trusts are discussing joining the pilot and sending teams to the next wave of training in 2016

Bulletin Contents


Click on the link to jump to that section

POD Project Update

 

Russell Razzaque
Associate Medical Director and Consultant Psychiatrist, Havering CRT, NELFT


 
I never cease to be amazed by the passion there is for POD to come to the UK. With the 550 places available to us, we figured that, if we promote it through our networks, we might just get close to filing the seats. However, the demand was so high that we ended up overbooking – more than 620 people - and still the requests kept coming in. In the end, unfortunately, we just had to start saying no, otherwise the hall owners wouldn't have allowed it to go ahead.

Then on the day, the response was unmistakable. “We want this in our area and we want it now”, was the chorus that chimed almost universally from service users and carers who attended. The sheer amount of hope and good will in the room was palpable. Our task now, then, is to take that forward and galvanise it into action for positive change. I intend to use this slot in the bulletin to map the course of that change, so that people will receive an update, both on where we are now, and on the plan going ahead, in each issue. It’s a plan that is fluid; constantly moulding and adapting to the circumstances we find ourselves in, as we attempt to capitalise on every opportunity that presents itself.

We are currently 4 Trusts undergoing the NHS POD training. As mentioned, there are now a number of different Open Dialogue trainings available in the UK, but this is the one that has been developed within the NHS – by and for NHS staff in order to move towards Open Dialogue within our services. We have, of course, been truly blessed by wonderful support from the international Open Dialogue community, who have been flying in from all over the world to deliver to us the training we need. Jaako Seikkula and Mary Olsen came to our January module, and they really took our understanding of Open Dialogue and our ability to practise it to new levels. In June we will have Mia and Kari from the original Finnish team in Tornio coming along, and we are all very excited about that. The homework has involved us starting network meetings – in a dialogical style – with some of the clients already being looked after by our teams. This has enabled us to really feel the new energy and it is having a profound effect on clients and clinicians alike. We are all entering a whole new paradigm in our work, as we sense something profound changing within us.

This process will continue, as our knowledge and skill in Open Dialogue grows over the rest of the training until October. At the same time, we will be developing specialised training for peer workers, who we are working to incorporate as integral members of each team. There has been some discussion as to whether this can be a paid role in each case, and we are in on-going discussion with local trusts around the issue. The training we develop this year will enable integrated peer workers to be part of each team - working dialogically alongside clinicians - and we hope that this might be possible on a paid basis for all who are involved.

The main clinical training ends in October 2015 and we will then have about 6-9 months to sort out the logistics in each of our Trusts that will enable us to operate Peer-supported Open Dialogue across the care pathway. This requires a lot of managerial support, and it is because we have committed medical and/or operational directors within each Trust, that we will be able to do this, but it will take time to fully organise this reconfiguration.

At the same time – i.e. right now – we are working with our panel of academics who are applying for a grant by the National Institute of Health Research (NIHR). This is led by Professor Steve Pilling who, incidentally, during the couple of hours he spent at our conference on March 11th, told me how sad the stories from service users and carers made him feel, and we both agreed just how important this work really is. We have a heavy weight team who will be submitting an application, we hope, in early May for a commission that seems to resonate strongly with what we’re doing. If we win that, then we would expect the funding to arrive in mid/late 2016, by which time, as mentioned above, the pilot teams would be up and running. This will be used to fund the evaluation. Thereafter, we should spend the next several years (perhaps as many as 6) comparing our POD outcomes to Treatment as Usual.

From the experience I have had working this way already, we should have some evidence to report within the first couple of years, and I very much expect to be publishing a lot of data as we go along. Also, several other Trusts are in discussions about joining the project and, of course, the more the better – the more families & service users will be able to experience POD, and the stronger our case will become.

So that’s where we are so far. And, yes, it is a long road to travel. But the change we want to see is not just in one team, or one area, but we want to see it happen nationally if not worldwide, and for this, we need to build an unassailable argument.

In the meantime, the more we are able to showcase the positive stories and passion that arises as a result of it, the more we can accelerate that trajectory. And, in this endeavour, I think every one of us has a role. Heroes like Annie Jeffries have taken the message far and wide, and I have no doubt that, as my CEO, John Brouder said, it is this growing clamour that will create an unstoppable momentum for change. And that is the wind in our sails.

POD trainers' reflections

 

Val Jackson
Family therapist and POD Trainer 


As a trainer on the POD course and a family therapist I came to the course excited, apprehensive and immensely hopeful. Could we train people from a wide range of backgrounds? The argument for 3 years is persuasive but I have a strong belief that our intensive one year course will enable many more to change their practice and improve services. There are one and two year courses in the US and in Germany.

My personal experience in Leeds has taught me that not everyone needs to be trained as a family therapist, support workers and people with personal experience often being some of the best practitioners. Very quickly it became apparent that the POD students were passionate about the training. I’m sure much of the credit for this is due to the ‘subject’, as Open Dialogue readily reflects the values that we hold. 

My main concern was how to ensure that all 50+ students have a worthwhile learning experience with only 2 tutors. Having a variety of excellent visiting speakers seems to help facilitate this for the majority, if not all. Mark, Russell and I are constantly learning too, and the feedback from the students helps us refine and make changes from module to module (fewer evening seminars being one of them!). The three of us work well together, each bringing a different perspective, with Russell being an amazing driving force. Ideas are rapidly bounced back and forth until we reach something that feels ok.

I look forward to being able to involve more of you in this collaborative process next year as we train the trainers. There is still a long way to go before the trial can begin, and a lot more learning to do, but I feel hugely privileged to be part of this journey.

POD trainees' reflections



Lauren Markham
STR Worker, Upminster CRT, NELFT


The POD training consists of four residential weeks in Birmingham split throughout a year with assignments, posts and readings in-between.

At first I was a little apprehensive at seeing the list of readings and assignments expected from us. As a support worker I didn’t have the academic backgrounds the doctors, therapists and nurses had - how would I cope? How would I also cope trying to fit it all in with my clinical practice too? The fears were not realised, it surprised me how easily I slipped into “Fronter.” Fronter is the online forum of sorts where we post about the training, literature, practice and mindfulness among others. It’s become almost like another member of the training group for many, including myself, where we can seek support from other trainees or just write posts for us and reflect for ourselves. The assignments focus on self-reflection and our journey as individuals which is so different from any other training or course I have done before; it took some getting used to but it is great to see how I am developing as the journey progresses. 

The weeks in Birmingham are almost like a sanctuary. There is a real energy in the room when all four trusts get together, there is something about all of us coming together with a prime goal to improve services and it feels to me as if everyone feeds on that. Since the course is intense the days can be long and it was daunting looking at the timetable, however the way the course was structured eased the long days. Full of discussions and role plays, the information is broken up so we aren’t sitting “lecture style” for a week, we all have a voice and are given the space to reflect and have our voices and opinions heard. Mindfulness is incorporated into the schedule and speakers such as Jaakko Seikkula and Mary Olsen really put everything into perspective and proved extremely valuable to the learning. Although intense,

I am thoroughly enjoying the training as I not only improve as a practitioner but as a person. There is a real sense this is something different, something positive and something which can make a real difference. Unlike anything else I have been involved in.   

 

Deborah Salter
Support Team Recovery Worker, Havering Community Recovery Team, NELFT


I attended the POD conference on the 11th March 2015 and upon arriving I was really pleased to be greeted by a queue that went out the door. I did not know at that time that as a VIP I could have jumped this queue so lined up with everybody else, however if Open Dialogue is a way of being and not just a way of working, then VIP lists are destined for the bin anyway!

Before going to this conference, I had been unaware of the level of interest POD had generated in all sorts of people. Obviously everybody on the training thinks it’s great but I have been on loads of training that people have liked. POD is different. The funny thing is that it gets people talking and that’s what the approach is supposed to do, amongst other things…Get people talking. As the place slowly filled with more and more people I began to get the impression that maybe I had not taken mine and Lauren’s invitation to be  ‘speakers’ as seriously as I probably should have done.

When the conference began it was really encouraging to hear the level of support there is for POD from people who are actually in a position to do more than just say ‘Things need to change’. I was pleased to hear John Brouder saying that he believes in Open Dialogue, and he is giving it his full support and Luciana Burger, Shadow Minister of State for Health, said we were on an incredible journey of transformation.

The part of the conference I enjoyed the most was the bit when people could comment on what they had heard and share their experiences of mental health services throughout the years. Somebody asked what the difference between a POD meeting and a Ward round was, and one man stood up and said he had been to a ward round and asked who the most important person in the room was and everybody pointed towards the consultant. In POD every voice counts equally.

All afternoon there were slides and research and things said, some of which I didn’t understand as somebody who has had no formal mental health training. It was all looking very organised and formal and very much like a proper conference should look. This made me quite nervous about the fact that both Lauren and I had thought it would be a fantastic idea to prepare NOTHING for what we were going to say and just show people what reflection, using the Open Dialogue model, looked like.

As time got closer to our 10 minutes I tried not to think too much about what to say so I focused on what the other people were saying at the time and tried not to plan. Despite my original concerns that it might be a bit weird to have a chat in front of nearly 600 people, our reflection seemed to go down really well, which was a relief.

The conference ended with more questions and answers and if I am really honest, I am glad that there appeared to still be some people who had reservations about POD. For me the point was not to preach to the converted or to get people to see that POD is the right way. I feel the conference was there to show people about Open Dialogue. Explain what it is and how it works. Give them the information and allow them to agree or disagree with what it involves.

I found the whole day inspiring and uplifting. I am looking forward to next year’s conference when we will have had more chance to practise and see results from POD. By that time we will be much further along in this ‘journey of transformation’ and I am very pleased to be part of it.
 

Please feel free to submit reflections on the trainee experience to podbulletin@gmail.com

POD in VIVO

 

Marianne Hayward
Consultant Psychiatrist, Havering Access and Assessment Team/Community Clinic, NELFT


So far, I’ve been involved with network meetings with one client and his mother. I already knew both of them through my psychiatric clinic, but the experience of meeting them with colleagues in their own home outside the usual structures and expectations of a psychiatric review has been an interesting one. Although much of the material we’ve discussed has been familiar to me, I’ve heard it set in a bigger context, and feel that I have a deeper sense of my client as a man struggling to manage distress at a very human level, deeper than the usual service user/professional divide.

As someone currently working in a short term, very discharge focused service it’s a huge challenge to step aside from the need to be always thinking about the next step towards discharge and allow the process to simply unfold, and after our first three meetings I have very little sense of how things will develop and whether our conversations will lead to any changes in his day to day experience. One thing that is clear however is that a man who has often felt dismissed and rejected by mental health services is experiencing our meetings as a sign of genuine interest and commitment to him, and that can only be a good thing.

 

Lucy Kilmartin
Higher trainee in General Adult Psychiatry, Redbridge Community Recovery Team, NELFT


I have been working with a family alongside colleagues from the POD team at Havering CRT for several weeks now. My experience of the network meetings thus far has been a profound and powerful one. Stepping outside the framework of expectations attached to the typical psychiatric consultation was initially challenging, as much due to my own expectations of myself and what I should "be doing" as due to the expectations of others. However, moving past this created a sense of freedom within the meeting, where we began connecting as people first and foremost, on a much deeper and more human level.

With the breaking down of barriers came an added feeling of reassurance, despite, perhaps paradoxically, sitting with more uncertainty at times. I think a certain sense of confidence and understanding came from being authentic and true to ourselves. My voice was heard alongside those of the other members and each of us felt a part of a mutual journey. The use of reflection within the sessions has often led to a significant emotional shift and this element of the process has therefore proved particularly interesting. 

Our network has slowly expanded over the course of the work, and the joining of additional perspectives and voices has indeed created a richer experience for us all. The flexibility of the approach, both in terms of network members' presence and the timing of meetings, has been empowering for this family. There are clear challenges ahead of us, but from my point of view, an Open Dialogue approach has felt positive and containing, by creating a safe space for new and important meanings to be shared. 
 

Please feel free to submit reflections on working with families and networks using the POD approach to podbulletin@gmail.com


 

Readers' responses


If you have any thoughts about, or feedback on, the content of this bulletin, please email us at podbulletin@gmail.com. We want to stimulate discussion and really value your views. 


Events and networking

 

Past events:  


Peer-Supported Open Dialogue conference, 11th March 2015, Regents Hall, London.  


Pictures: top: the conference taking place in Regents Hall; below: speakers (clockwise) Dr Russell Razzaque, Consultant Psychiatrist, Havering CRT, NELFT; John Brouder, Chief Executive, NELFT; Val Jackson, Family Therapist and POD trainer;  Mark Hopfenbeck, Assistant Professor, Gjøvik University College, Norway and POD trainer; Luciana Berger MP, Shadow Minister for Public Health.
 

Many thanks to all who attended the conference on March 11th.

For those who would like a recap, or missed out on any of the talks, you can view the presentations via the NELFT website here: 

NELFT Open Dialogue Conference website

and a short video clip from Green Lane Films here: 

POD Conference on YouTube

Psychiatry at the Theatre: Review

 

Lauren Gavaghan

Specialist Registrar in Adult Psychiatry

 

The Eradication of Schizophrenia in Western Lapland by John Hayes and David Woods, Battersea Arts Centre


Open Dialogue, the Finnish (Western Lapland) approach to the treatment of mental illness, is a ubiquitous theme within the play entitled ‘The Eradication of Schizophrenia in Western Lapland’ and as a psychiatrist currently undertaking training in this approach, it is timely. The performance reverberates powerfully at a time when the Royal College of Psychiatrists states that mental health services are at breaking point, with the shortage of hospital beds becoming concerning.  

The play is remarkable, and though aesthetically the set is relatively simple, complexity abounds. The stage is split into two adjacent rooms separated by an open doorway and the audience to each ‘stage’ is shielded from one another. We participate in an intentional switching of seats during the break.  We are 'split' in our views, physically and psychically and akin to a drawn-out psychotherapeutic encounter, there is finally a glimpse of integration of the split parts, as the characters take their final bow.

We are left acutely aware that we merely but tasted parts of the whole picture. This realisation becomes ever more glaring in the quoting of R. D. Laing's words on stage, a reminder that we never truly understand the other. Yet throughout, we are challenged to respect another's 'otherness' and allow for a shared language to develop, a foundation upon which the Open Dialogue approach rests.  We are invited to witness the unfolding of two intertwined stories. A family unit, disintegrating and descending into the murky quagmire of psychotic experience. A mother, chaotic and lost amidst the multitude of voices she hears, rapidly spirals into anger and desperation. The juxtaposition of one son, relatively coherent on one stage, soon begins to voice his own grandiose and fantastical ideas. We see suffering played out, no more so obvious than in the beautifully conceived few moments of the younger son being offered medication to treat his mother.

What follows is a beautiful yet tragic enactment of what might represent a dystonia, his body writhing uncontrollably down one side, coupled with an immediate and deadly silencing of his voice.  We are challenged in our interpretation of psychotic experience and watch both the destruction and re-building of characters and experience, and the subsequent meaning that evolves. We tentatively build up a story of the family we see in front of us. It is complex and confusing and we are lured to see the dangers in categorising and compartmentalising mental illness.  

The performance is intricate and each 'half' of the act beautifully synchronised. In moments the chaos is palpable, yet it feels strangely normal at times.  We are encouraged to question. Who is mad? What is mental illness, a diagnosis? Who constructs what? When context is all, and depicted so vividly, these questions shone neon against the black curtain keeping us in the dark until we dared widen our perspective.  

We left ever more curious and enriched. Something was learnt. We are invited to consider new ways of perceiving, and ultimately, the potential of 'being with,' rather than 'doing to.'  

Upcoming events:

 

Open Dialogue: Experience in the UK 


Friday 15th May @ 54 St James Street Conferencing & Business Centre, Liverpool, L1 0AB
Contributors: Anna Arabskyj, Corinne Hendy,  Mark Hopfenbeck, Marc Hudson, Val Jackson, Catherine Kinane & Russell Razzaque.


Why is interest in Open Dialogue growing so fast in the UK?  What is the experience of Open Dialogue actually like?  Is it relevant for you - should you be getting involved?  This is a day for anyone wanting answers to these  questions, and suitable for professionals of all disciplines, those who commission services,  people with personal experience of psychosis or family members, and anyone trying to support people experiencing psychosis. As well as covering the principles of Open Dialogue, recent UK developments, and the planned UK wide research programme, speakers will talk about their personal experience of: dialogical practice as client, family member and practitioner; participating in Open Dialogue in Norway; participating in UK training in Open Dialogue, with perspectives from a peer support worker and a psychiatrist; obtaining funding for Open Dialogue developments in the current climate of austerity. There will be opportunity for first hand experience of dialogical practice. Please note: participant numbers will be limited to make this a worthwhile experience.    
 
Book your place online at www.ispsuk.org or via admin@ispsuk.org

Only Us Campaign:


Please click on the link below to hear more about the "Only Us" campaign, which aims to promote understanding, compassion and unity around mental health issues.

Only Us

If you would be interested in setting up and running a Facebook page for the Only Us campaign, please email podbulletin@gmail.com
 
If you would like us to feature any upcoming or past events, please contact us at: podbulletin@gmail.com 

Recent publications



Please click on the link below to view our letter to the Guardian about Peer-supported Open Dialogue following March 11th conference in London:

Guardian letter
 

Please click on the link below to access the following article:

Razzaque R., Wood L. (2015). Open Dialogue and its Relevance to the NHS: Opinions of NHS Staff and Service Users. Community Mental Health Journal.

Article

Commentary

 

On Open Dialogue and Healing

 

Tom Stockmann
Medical Education Fellow, NELFT

 
 
The Open in Open Dialogue

Open in Open Dialogue refers to two different but linked concepts. One is transparency. No decisions about the person in distress are made outside of the network meetings, and within this setting the clinicians openly discuss their observations. The clinicians are part of the polyphony – they are ‘with, not doing to’.

The clinicians reflect with their authentic selves, the second aspect of openness. They generate a true human-human relationship by bringing their own emotional responses to what they hear. The aim is to avoid objectification and distance between clinicians and others.

In this regard, Open Dialogue is in debt to the insights of Carl Rogers, the founder of person-centred therapy. Open Dialogue clinicians need to embody the three basic Rogerian features of a therapist: congruence (transparency), unconditional positive regard, and empathy.  
 

Carl Rogers


The clinicians’ role is not to bring ‘truths’, but their own (personal, but not private) selves. In order to avoid bringing aspects of themselves for the wrong reasons, self knowledge is crucial. This is one reason mindfulness is a key aspect of Open Dialogue.

Mindfulness

J Bobrow, a psychoanalyst and Zen master, spoke about the cognitive, emotional and somatic aspects of reverie. He describes how the help we look for when in distress begins by us stopping, looking, and listening – allowing us to attend to what is happening within us and around us in a different way.

Stern speaks about the importance of being aware of what is happening within us (implicit knowledge) before we give words to it (explicit knowledge) – allowing us to express the feelings that accompany our own narratives. Communication of  such feelings is less rational, and more authentic, as psychological defences do not interfere to make the material ‘more suitable’ for others to hear.

In Open Dialogue, therefore, clinicians need to pay attention to the present moment, to sense the emotion in all communication – verbal and embodied – in both them and in others. For example, physiological signs, such as change in breathing pattern, or a shifting of position, may indicate an emotional response to what has just been discussed.

During the dialogue, clinicians may not necessarily join the dialogue with speech, but will remain present in other ways, such as body posture, gestures, and facial expressions, all of which have been shown to be of significance to patients.

The Platonic ideal of a network meeting is the emergence of living persons in authentic contact with each other, adapting to each other in the moment, communicating at a level before words are consciously chosen – a Buberian meeting.

The Dialogue in Open Dialogue  
 
“The mystical physician to the king of Thrace said the soul was treated with certain charms, my dear Charmides, and that these charms were beautiful words.”
– Plato, Charmides

The primary emphasis in Open Dialogue is on the generation of dialogue, rather than promoting change directly. The aim is for the dialogue to allow the network to summon their own psychological resources with which to deal with the problem.

In acute emotional distress, network members may feel desperate, stuck, and rigid in thinking, making understanding and communicating difficult. The role of the clinical team is to support the expression of emotion. They haven’t experienced the trauma firsthand, and so do not share in its intensity, although will of course be moved to some extent. The clinicians’ skill is in holding the strong emotions present in the room, allowing network members to contribute to a dialogue despite these being there.  
 
‘One speaks as a listener’
– Hoffman

As the problems (e.g. psychotic symptoms) are assumed to be socially constructed, they can be reconstructed in each conversation. The starting point is the actual language used by family to explain the problems. The clinical team follows the words used, but refrain from interrupting, or offering interpretations or hypotheses, as this may silence a new voice with an alternative explanation, and may bring the conversation back into the rational, guarded realm.

Every utterance is acknowledged, with all voices unconditionally accepted – as Bakhtin put it – all network members are “without rank”. If this is not the case, the conversation risks becoming a monological rather than a polyphony. In considering the clinician-patient relationship, Shotter differentiated between the “withness” during dialogue, and the “aboutness”  of a monological meeting.

In a polyphony, members can see that their words are accepted by others, allowing them the safety and confidence to reflect on their meaning. Thus, through language the meaning of the symptoms may be explored by the network. It is this process, rather than the eventual content, that is important. This process occurs between the people within the system – in the intersubjective space.

Reflection

Within the meeting, clinicians offer their reflections. There is no specific reflecting team (as in family therapy), but when it is felt appropriate during the meeting, the clinicians may have a reflective conversation by switching from ‘interviewing’ to having a dialogue with each other only, during which time they avoid eye contact with the other network members.

If the dialogue is to be transformative, the clinicians must remain present in the living moment. They do not enter the meeting with an agenda, or having particularly prepared. The conversational path taken is improvised – the clinicians following Ariadne’s thread through the Labyrinth of language.  In contrast to the trial and error method, there are multiple possible routes to be taken, with backtracking allowed. As Jean Franco-Lyotard (via Wittgenstein’s language games) may have put it – dialogical practice is a ‘game without an author, as opposed to the scientific or ‘Western’ ‘game of speculation’.

Or as Rilke, with characteristic eloquence, said: “Live your way into the answer”.  

 
Ariadne and Theseus by Niccolò Bambini.
Ariadne gave Theseus a ball of thread to find his way out of the Minotaur’s labyrinth


Tolerating Uncertainty  
 
“Both knowing and not knowing – one of the most human arrangements.”
– Saul Bellow, Mr Sammler’s Planet

One of Bion’s concepts was the ‘catastrophic change’. He said that the psyche perceives each new thought as potentially damaging. It is painful, but to become able to tolerate this leads to personal growth – to increased resilience to anxiety, doubt and destruction. With this idea, Bion reminds us of Keats’ ‘Negative Capability’, and the importance or tolerating uncertainty.

During the evolution of family therapy, therapists encountering complex situations decided to free themselves from a futile search for truth, and accept the uncertainty. The use of a particular technique made way for more of a collaborative conversation. This idea has been transferred to Open Dialogue. There is no looking for a particular truth, just the aim of facilitating the expression of multiple voices, each containing their own truth.

In Open Dialogue every crisis is assumed to be unique. Hasty decisions are avoided, and it is accepted that understanding is a gradual, organic process. No important decisions may be taken for first 2-3 Open Dialogue meetings, even if the distress is severe. This is not to say that medication and hospital admission are never used, but efforts are made to expand the dialogue, and to sit with the discomfort, risk, and not knowing, rather than acting immediately. Everyone in the meeting shares this uncertainty. Some responsibility is shifted back to the network, and the senior doctor is no longer the main recipient of the burden. Together, all come to realise that the situation can be endured. The ambiguity is undone through shared language; dialogue dissolves the need for action.

Early on, meetings may be very frequent to create a sense of safety. Over time, the network gains language to express experiences and builds up its inherent resources. Gradually, the crisis may become an opportunity for positive change – a chance to retell the stories, remake the identities and rebuild the relationships that form the self and the social world.

Healing

In Open Dialogue, healing occurs when the speaker is moved. If the clinician remains in the moment – open to authentic human warmth, present in Bakhtin’s ”once occurring participation in being”, they will be sensitive to the ‘striking moments’, or moments of ‘aliveness’, when someone is touched by something new and a transformation is allowed to happen.

Love

Let us finish by returning to the mother – baby archetype, and its parallel in the clinician – patient relationship.  



Just as the mother experiences loving feelings toward her child as they engage in mutual emotional regulation through dialogue, in Open Dialogue the clinician knows that experiencing loving feelings toward the patient indicates effective mutual emotional regulation, and the first spark of healing.
 
“Love is the life force, the soul, the idea. There is no dialogical relation without love, just as there is no love in isolation. Love is dialogic”
– Patterson. Literature and spirit
 
(Previously published at https://tomstockmann.wordpress.com/)

 Please submit any commentaries on current literature, or reviews of published articles, to podbulletin@gmail.com

Social Media Bite


Here's the latest edited clip of the 2015 conference, and a way of spreading the message of our joint journey far and wide, so please feel free to watch, tweet, link, like and share!

If the video doesn't appear below, please click here.
Video of Peer Supported Open Dialogue Conference 2015 UK
UK Peer-supported Open Dialogue Conference video
Created by Green Lane Films
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Copyright © 2015 Peer-supported Open Dialogue UK, All rights reserved.


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